Geriatric Incontinence and LUTS

1. Geriatric Incontinence and LUTS

2. Objectives • Recognize age related lower urinary tract changes • Appreciate unique aspects of geriatric voiding problems • Distinguish among various forms of incontinence • Appreciate how non-urinary issues contribute to continence

3. Key Points • LUTS are common among the elderly • Patients frequently don’t mention it & physicians often don’t ask • Both patient and doctor frequently consider it a part of “normal aging” • LUTS are morbid, costly and lead to poor QOL • Majority of patients can be helped

4. Case Presentation • 84 yo male with spinal stenosis/immobility, mild dementia and parkinsonism develops fecal impaction and acute urinary retention. Prior to this he had frequent urgency, nocturia and occasional incontinence • Urinary catheterization 1.5 liters urine • Moderate size prostate • No hematuria, urine culture negative • PSA 4.2

5. Acute Management • What is the appropriate immediate management? • Refer for TURP • Intermittent clean intermittent catheterization • Begin alpha blocker • Place Foley and begin alpha blocker, treat fecal impaction

6. Long Term Management • Failed 3 voiding trials (persistent retention) over 4 weeks • How do you manage at this point? • Proceed with surgical options immediately • Continue more voiding trials • Clean intermittent catheterization • Chronic indwelling Foley

7. Voiding Hesitancy Poor flow Intermittency Straining Terminal dribble Storage Urgency Frequency Nocturia Urge incontinence Lower Urinary Tract Symptoms

8. Changing Paradigm of LUTS • Historically men with LUTS were considered to have “prostatism” • Elderly patients show higher rates of persistent symptoms/dissatisfaction after TURP • Women frequently assumed to have stress or urge incontinence • Surgical procedures, pessaries, Kegel’s exercise

9. “The Bladder Is an Unreliable Witness” Bates 1970

10. The Unreliable Witness • Many asymptomatic elderly have UD evidence for detrussor overactivity • UD evidence of bladder outlet obstruction can be completely asymptomatic • Elderly woman frequently have high scores on IPSS and AUA symptoms scales • Among elderly men with BPH, many have residual symptoms after TURP

11. ICS Definitions • Urgency • “Sudden compelling desire to pass urine which is difficult to defer” • Differs from the “normal desire to void” • Pathological • Frequency • The complaint that an individual urinates too much, typical ~8x/day • Nocturia • The complaint of awakening to void >1 time/night • Urge Incontinence • involuntary leakage accompanied by or immediately preceded by urgency

12. Increased Detrussor over activity Nocturnal urine output BPH Post void residual <100cc~90% Bacteruria~20% Decreased Bladder contractility Bladder sensation Sphincter strength LUT Changes in Aging

13. LUTS and Aging • Almost always multifactorial • Age associated LUT changes and comorbid disease associated • Major impact of conditions beyond the urinary tract in LUTS • Mobility, dexterity & cognitive influence on continence

14. Aging and Continence • Most elderly people remain continent in spite of age associated LUT changes • Multiple factors interact to determine continence status • Intervention on all the contributing factors frequently yields good results • Looking for the one cause is wrong paradigm

15. Cerebral Control of Micturition • Increasing research reveals that much of geriatric voiding dysfunction is “beyond the bladder” • Cortical & sub-cortical control over bladder function • Mostly inhibitory control that requires intact attention, working memory, executive functions

16. Incontinence • Common, morbid & costly • 25% of community dwelling elders are incontinent • 50% of nursing home residents • Leads to isolation, embarrassment, depression • Associated with falls, fractures, skin problems and institutionalization

17. Why is Incontinence Important? • Social Stigma – leads to restricted activities • Depression • Medical complications – skin breakdown and • Increase in urinary tract infections • Institutionalization – UI is the second leading cause of nursing home placement

18. Types Incontinence • Transient vs. chronic • Stress • Urge • Overflow • Functional

19. Transient Incontinence • Delirium • -Infection • -Atropine vaginitis or urethritis • -Pharmaceuticals • -Psychological disorders • -Endocrine Disorders • -Restricted mobility • -Stool impaction

20. Stress Urinary Incontinence • Involuntary leakage on effort or exertion, or on sneezing or coughing • The sign of stress incontinence is the observation of urine loss from the urethra during coughing or straining • Cough stress test may be useful • Tends to be small amounts of leakage

21. Overflow Incontinence • Leakage of urine associated with urinary retention • May be due to bladder outlet obstruction or poor bladder contractility • BPH with BOO • Urethral stricture, tumor • Diabetic cystopathy, multiple sclerosis, cauda equina etc. • Urodynamic studies to evaluate pressure/flow

22. Overactive Bladder • Urgency, with or without urge incontinence, usually with frequency and nocturia . . . if there …is no proven infection or other etiology • Equally common among men and women in the very elderly • 2/3 of OAB patients are “dry” • Dry patients still suffer

23. OAB Symptom Definitions • Urgency: a sudden compelling desire to pass urine that is difficult to defer • Urgency Urinary Inc. (UUI): involuntary leakage accompanied by or immediately preceded by urgency • Frequency: 8 voids / day = “normal” • Nocturia: patient wakes one or more times at night to void (sleep “before” and “after”) Abrams P, et al. Urology. 2003;61:37-49.

24. Prevalence of OAB Age and Gender • Prevalence of OAB • Men: 16.0% • Women: 16.9% Stewart WF, et al. World J Urol. 2003;20:327-336.

25. OAB Treatment Rates by Age Group Source: IMS Retail Perspective

26. Usual Evaluation • History • Urge • Stress • Symptom scales • Physical examination • Pelvic, rectal/prostate, abdominal, neurologic, cognitive, cardiac/pulmonary • Cough stress test • Labs • Urinalysis, culture?, ?psa, post-void residual • Frequency volume chart

27. Detrussor Hyperactivity with Impaired Contractility • DHIC common among frail elders • May predispose to acute urinary retention • Elevated PVR • Bladder is both paradoxically weak and overactive

28. Behavioral Management • Pelvic floor exercises • Bladder training • Biofeedback • Prompted voiding • Fluid limitation • Dietary modifications • Continence products

29. Expectations of Treatment • Complete dryness may not be feasible • Decreased urgency episodes • Decreased incontinent episodes • More lead time • Tolerability of current therapies

30. Newer OAB Medications • Oxybutinin • Immediate, delayed release, patch form • Tolteradine • Immediate, delayed • Trospium • Darifenacin • Solafenacin • Immediate and long acting form

31. OAB Therapy for Refractory • Botulinum toxin injection • Neurostimulator • Vanilloid bladder washings

32. When to Refer • Failure to improve with current therapy • Persistently elevated PVR • Interest in surgical/interventional options • Complex neuro-urological cases • Abnormal findings (hematuria, hydronephrosis, elevated PSA, etc.)

33. LUTS in Men Recent Advances • IPSS scores not specific for BPH with BOO • Combined BPH and OAB therapy • PDE inhibitors • Nocturnal polyuria therapy

34. Case Presentation • 83 yo male complains of 5-6 episodes of nocturia for the past 6 months. • Denies dysuria, straining, or hesitancy, past episode of transient acute urinary retention during hospitalization for knee replacement 4 years ago. • Exam shows enlarged smooth prostate, moderate peripheral edema, and venous stasis changes

35. Which is the most likely to be helpful? • Trial of alpha blocker • Urinalysis • Overactive bladder medication • Trial of 5-alpha reductase inhibitor • Referral for TURP • Voiding diary and compression stockings

36. Diagnosis? • Benign prostate hypertrophy • Urinary tract infection • Normal aging • Overactive bladder • Diabetes insipidus • Nocturnal polyuria

37. Nocturia • Definition • Waking up to void one or more times during the night • Voiding during intended sleep time that is preceded and followed by sleep • Associated with mortality • Disruptive to sleep, contributes to fatigue • Increased risk for falls 10% vs. 21% with 2 or more voids

38. Prevalence of nocturia in men 1 void 2 voids Percentage of men with nocturia Age range (years)

39. Prevalence of nocturia in women 1 void 2 voids Percentage of women with nocturia Age range (years) van Dijk et al. 2002

40. NOCTURIA Bother No Bother No Presentation Patient Presents Screen Advice Further Evaluation Polyuria Nocturnal Polyuria Apparent Bladder Storage Problems Other Classification Primary Sleep Disorder Diagnostic algorithm

41. Nocturnal Polyuria • >33% of total urine volume produced while asleep • Changes in atrial natriuretic peptide, ADH secretion • Consider occult sleep apnea • 30-40% will have significant OSA • CHF and venous insufficiency • Therapeutic options • Limit evening fluids/behavioral modification • Evening loop diuretics • DDAVP therapy • Dried fruits?

42. Pharmacological treatment of nocturnal polyuria Diuretics • Helpful in patients with lower limb venous insufficiency or congestive cardiac failure • Level 1 evidence, Grade C recommendation • Bumetanide 1 mg p.o. in afternoon • Furosemide 40 mg p.o. in afternoon Antidiuretics • Helps retain water until a more appropriate time • Reduce nocturnal voids and voided volume • Level 1 evidence, Grade A recommendation • Desmopressin 0.1 mg p.o. titrated to 0.4 mg • No direct bladder effect • No direct cardiovascular actions

43. History/Clinical Assessment Presumed Diagnosis Bothersome Nocturia • MEDICAL HISTORY • Other urinary tract symptoms/ Sleep history/ Drinking habits (quantity and type)/ Medication (e.g., diuretics) • EXAMINATION • Ankle oedema/Abdominal examination/Prostate assessment/Female pelvic assessment/Assess post-void residual urine • INVESTIGATIONS • Urinalysis – if infected, treat and reassess Frequency Volume Chart • GLOBAL POLYURIA (24h voided volume >40 ml/kg) • Electrolytes • Serum glucose NOCTURNAL POLYURIA (nocturnal urine volume > 33% of total 24h urine volume (age dependent) • OTHER AETIOLOGY • Overactive bladder • Bladder outflow obstruction • Sleep disturbance • Cardiac disease • Gynaecological abnormality • Bladder pain or bleeding Lifestyle advice Lifestyle advice Non-responders Treatment Further evaluation and appropriate treatment • Desmopressin bed-time • Furosemide in the afternoon Non-responders Non-responders Non-responders Specialist referral

44. Summary • Incontinence is not a “normal” part of aging • LUTS and OAB are very common • Most LUTS in the elderly are multifactorial • Don’t assume BPH is the etiology among elderly men • Use frequency-volume charts to diagnose nocturnal polyruria • Multiple treatment options exist for most